THE C.H.A.N.G.E MANTRA
THE C.H.A.N.G.E MANTRA
Leadership Program Application (July 29-31, 2014) Elizabeth City, NC
Indicates required field
Grade for 2014-2015 School Year
Please indicate your t-shirt size.
Parent's/Guardian's Phone Number
If you do not have an e-mail address, please input the following: firstname.lastname@example.org
Please list other activities student is involved in:
Does the student plan to take advantage of the overnight residential option? **Overnight Lodging is Available for a $65 flat fee for 3 Days and 2 Nights on the campus of ECSU. This is highly encouraged, but not mandatory. If staying overnight all participants are expected to stay the entire duration of the program.
Yes, I will stay on campus.
No, I will not stay on campus.
The Overnight Option is highly encouraged, but not required.
Limited Sponsorships for Lodging costs may be available.
Contact email@example.com or Dr. Jametta Davis at 703-899-0482
What is the best way to reach you (Check All that Apply)
Check All that Apply
(Family Member, Family Friend, Community Leader, etc)
Adult Recommendation can be a Family Member, Community Leader, etc.
Position/Relationship to student
Why do you recommend this student for this program?
Does the student display any behavioral issues that might interfere with working in a team environment during the workshop?
Yes, Please Explain Below
Please explain any behavioral issues here.
If the answer is no, please write N/A. If the answer is yes, please explain the behavioral issue(s) here.
What are some focus areas that woud benefit this student?
All Applicants Must Complete This Section
My goals are:
List your hopes, dreams, desires, or even your summer or academic goals. We just want to know more about you!
I want to improve in the following areas. Check all that apply.
Decision Making/Problem Solving
Please tell us about yourself and why you are interested in the Girls Run the World Summer Leadership Program.
We want to know more about you so we can tailor the workshop, so come on tell us a little about YOU!
Why do you believe it is important for girls and women to become leaders in society?
There are no right or wrong answers here. Just write what you think.
Give one example of a way in which girls and women are negatively portrayed in media (TV, music, social media, etc.) and its impact on self-esteem.
There is no minimum or maximum number of words for your response. Please answer this question to the best of your ability.
Applications can be submitted by pressing the button below, if you make an error or need to amend the application, please e-mail us at
or contact the Elizabeth City Program Director (information below).
Melba Smith, 252-335-3985,
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